The effectiveness of a health promotion program for the low-income elderly in Taipei, Taiwan

Journal of Community Health, Vol. 29, No. 6, December 2004 (Ó 2004)

THE EFFECTIVENESS OF A HEALTH PROMOTION PROGRAM FOR THE LOW-INCOME ELDERLY IN TAIPEI, TAIWAN I-chuan Li, DNS, RN

ABSTRACT: This study assessed the effectiveness of a health promotion program for low-income elderly provided by trained low-income home health aides. Indicators of the effectiveness of this program included improvement in physical health, psychosocial health and functional status, including activities of daily living (ADL) and instrumental activities of daily living (IADL) as well as changes in perceived health promotion needs. This evaluation study used a single group pre- and post-test experiment design. After informed consent forms were signed by participants, 89 purposively selected low-income elderly (aged 64–96) completed pre-test structured surveys, while 60 participants (aged 68–96) completed post-test surveys. Post-test scores indicated improved nutritional status (paired t ¼ 2.64, p < .05) and chore management of IADL abilities (paired t ¼ 2.83, p < .01). No significant difference in psychosocial status were found between pre- and post-test scores. Perceived needs for health promotion services decreased after the intervention.

The results show that the health promotion services were effective in improving health status and decreasing perceived needs for services among low-income elderly in Taipei. Recommendations based on this study for developing services for the low-income elderly must take health promotion intervention into consideration.

KEY WORDS: health promotion; program evaluation; low-income elderly.

INTRODUCTION The elderly population aged 65 to 84 is the fastest growing cohort in Taiwan.1 Persons aged 65 and over have increased from 7.0% of the total population in 1993 to 9.02% in 2002.2 Projections suggest that about 15% of Taiwan’s population will be 65 years of age or older by 2021. With advanced age, health impairment and disability increases.

According to Wu, more than 70% of people over 65 have at least one I-chuan Li is Associate Professor of Community Health Nursing at National Yang-Ming University, Taipei, Taiwan.

Requests for reprints should be addressed to Dr. I-chuan Li, Institute of Community Health Nursing, National Yang-Ming University, 155 Li-Nau St. Sec.2, Taipei 112, Taiwan, ROC; e-mail: icli@ym.edu.tw.

511 0094-5145/04/1200-0511/0 Ó 2004 Springer ScienceþBusiness Media, Inc.

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chronic medical condition and about 5.4% of them require assistance with activities of daily living.3 In Taipei, about 12,073 persons, or 1.13% of the population, were classified as low-income in 2002. People in poverty have increased from 0.7% in 1998 to 1.13% in 2002. This growth can, to some extent, be attributed to rising unemployment rates and to changes in the labor market which have resulted in an increase in the number of people in low-paid employment.4 These figures are certainly low, however, as regulations for defining who falls below the poverty line are rigid. According to the Directorate General of Budgets, Accounting and Statistics, the poverty line has been calculated as 60% of the average per capita consumption expenditure during the past year. For example, in the second half of 1999 and in 2000 the minimum income required to be considered above the poverty line in Taipei is 11,625 TWD per month (about 322.91 USD).5 Old age ranks among the leading causes of poverty,6 and there is evidence to demonstrate the connection between poverty and old age, sickness and disability.7–9 Low-income people have higher mortality rates, shorter life expectancies and lose more years of life due to various diseases than do people who are not poor.10 Also, those living in poverty experience more chronic medical conditions along with symptoms of illness and disease, and they are more likely to have activity limitations.11 Taiwanese low-income elderly are especially less likely to engage in health promotion and are much more likely to be pessimistic about their health, leading to chronic health problems such as hypertension.12,13 The low-income elderly have poorer health due to difficulties in accessing basic requirements for good health such as adequate housing, food, water supply and medical and health care services.12,14–16 Furthermore, policy makers have been reluctant to acknowledge the links between poverty and ill health; anti-poverty policies in Taiwan have put too much emphasis on financial assistance not enough on self-care, independence and healthy lifestyles. Even more, most studies on poverty in Taiwan analyze its structure, but very few look at social and health needs.

While the focus of poverty in the West has shifted in recent years from ill health to ‘‘lifestyle’’ and ‘‘health promotion,’’ i.e. smoking, unhealthy diet and lack of exercise,14 low-income populations are still seldom sampled or included in intervention studies of health promotion.17 Thus, the challenge for public health nurses is to promote health in conditions of poverty.

Health promotion means different things to different people.

Health promotion strategies can be extremely beneficial in the maintenance of functional health, especially for the elderly, as diminished func-

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tional health status is the primary cause of loss of independence.18 According to Kate, health promotion has been categorized into three activities: prevention, protection and health education.13 Prevention would include screening for hypertension and physical examination. Protection would include such things as non-smoking and the provision of attractive leisure activities to improve fitness and social health. Health education is an act of communication that might include information about the body and how to look after it, or information about health services.

The low-income elderly do not have the time or energy to devote to health promotion activities while struggling to meet the basic needs for living. Health promotion services to the elderly can increase their quality of life and their ability to independently manage their daily living activities. There is a need, therefore, to develop effective programs to: a) address health promotion activities for use by the low-income elderly; and b) to evaluate the effectiveness of these health promoting activities.

The purpose of this study was to assess the effectiveness of health promotion services to the low-income elderly upon changes to their health status, activities of daily living and perception of health promotion. More specifically, this study: 1. Examined differences between scores on physical health before and after the implementation of a health promotion program for low-income elderly participants; 2. Examined differences between scores on psychosocial health before and after the implementation of a health promotion program for low-income elderly participants; 3. Examined differences between perceived health promotion needs before and after the implementation of a health promotion program for low-income elderly participants.

METHODS Sample Selections Names and addresses of low-income elderly people were obtained from the Social Welfare Department in Taipei. Inclusion criteria were that subjects were low-income elderly in the Peitou area of Taipei aged 65 or over living at home and receiving government assistance. One hundred and sixty persons living in the research areas met these criteria and were approached by the principal investigator, who

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obtained the consent of 90 of them by telephone. A letter of consent describing the study was given to all subjects and signed by them or, if unable to sign due to illiteracy or physical disability, by their families. Sixty subjects completed the 8-month study. Thus, 89 subjects completed the pre-test questionnaire and 68% (60/89) of them completed both the pre- and post-tests.

Study Design This study was approved by the Human Subjects Committee of the Veterans General Hospital in Taipei City, and used one group preand post-test experiment. Low-income elderly participants were evaluated prior to and after participating in the program. A follow-up survey was conducted with the participants 8 months after intervention.

Intervention During the period of intervention, subjects received an 8-month program utilizing direct personal visits by trained low-income workers as well as phone-counseling by five graduate nursing students. This was a project on health promotion services for the low-income elderly in the Peitou district of Taipei conducted from 1998 to 1999. The principal investigator received the assistance of the Taipei Social Welfare Department in developing the health promotion programs. The project was carried out in two phases: a) training the low-income workers; and b) developing a program for the workers to provide health promotion services to the low-income elderly.

During the first phase, 30 workers received 40 hours of training over a period of 2 weeks. Content included methods for communicating with elderly people, ways to maintain a healthy lifestyle, illness prevention, nutrition, exercise and medication. Five graduate nursing students, also experienced clinical nurses, taught the classes and supervised skill acquisition.

The second phase consisted of developing a program for assigning this same group of workers to positions providing health promotion services to the low-income elderly. Six types of services provided by trained low-income workers based upon the results of the needs assessment of subjects surveyed by five graduate nursing students were as follows: medical (referral services), nursing (nursing referral services and screening for hypertension), home-making services (meal delivery, assistance in feeding, assistance in bathing, assistance in going outside, clean-

I-chuan Li 515

ing house, assistance in shopping and assistance in medical visits), caring services (personal greeting, telephone greeting and assistance in leisure activity), health education (reminders to take medications, nutrition and regular physical examination), and financial assistance services (referral for financial assistance, information about dentistry or hearing aides and financial consultation).

The program consisted of five levels of services determined by the frequency of home visits required (every 2 weeks, once a week, two visits per week, three to four visits per week or daily visits) that were based upon an individual’s health status. Included were activities of daily living, instrumental activities of daily living and family support. Each visit could not last longer than 2 hours, as per government regulations. The principal investigator decided the level of intervention needed according to the results of needs assessment and phone-counseling performed by the graduate nursing students. She met with the workers at the beginning of each week to discuss the subjects’ conditions and difficulties confronted during the last week, and also provided needed updates. On-the-job training was provided based on the suggestions of the workers about content/ skills needed.

Measurement Structured questionnaires were the primary sources of measurement. The instruments obtained information by means of a selfreport. Assessments were made based upon the following indicators: 1) demographic profile; 2) health status, including physical and psychosocial aspects; 3) functional status, including activities of daily living (ADL) and instrumental activities of daily living (IADL); and 4) perceived health promotion needs, including medical, nursing, home-making services, caring services, health education and financial assistance.

Demographic Profile Information on age, gender, educational status, marital status and living arrangement.

Physiological Health Status The physiological health status scale developed by Li et al. (2001) to assess chronically ill patients’ health status was modified to suit the low-income elderly of this study.19 The original scale consisted of 19 questions. Experts recommended retaining five questions that related to the patients’ mobility, while the other 14 questions provide data

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concerning vision, hearing, respiration, nutrition, sleep, circulation, comfort, excretion, speech, genito-urinary function, gross appearance, chewing, cognition and skin integrity. Responses were rated on a 5-point Likert scale ranging from 1 (best health) to 5 (worst health), and scores ranged from 14 to 70. A Cronbach alpha coefficient was used to assess the internal consistency of this health status instrument. It was .87.

Psychosocial Health Status After reviewing the related literature,20 and interviewing lowincome elderly, the current researcher developed a psychosocial health status tool comprised of five questions: emotional stability, interaction with neighbors, emotional status over the past week, arguments and fights with families during the past week and ways of dealing with emotional disturbances. These questions were rated on a 5-point Likert scale ranging from 1 (best health) to 5 (worst health); scores ranged from 5 to 25. A Cronbach alpha coefficient was used to assess the internal consistency of this health status instrument. It was .74.

ADL and IADL Subjectsâ&#x20AC;&#x2122; ADL and IADL were measured using a Katz scale. Five questions were used to assess ADLs: eating, bathing, moving between bed and wheelchair, personal hygiene and dressing. Five IADL questions were assessed: household tasks, shopping, food preparation, laundry and letter writing. A 3-point Likert scale ranging from 1 (better ability) to 3 (worse ability) was used to rate ADL and IADL. The Cronbach alpha for ADL and IADL were .99 and .98, respectively.

Perceived Health Promotion Needs The researcher developed this instrument after reviewing the literature regarding to health promotion and needs for low-income elderly.13,14 In this study, perceived health promotion needs were divided into six categories: medical, nursing, home-making services, caring services, health education and financial assistance required for health needs.

The first subscale contained one question related to medical referral services, and two questions on skilled nursing services (nursing referral service and screening for hypertension). Seven questions comprised home-making services (meal delivery, assistance in feeding, assistance in bathing, assistance in going outside, cleaning house, assistance in shopping and assistance in medical visits). The subscale for needs of caring services contained three questions: personal greeting, telephone greeting and assistance in leisure activity. The subscale on health education ser-

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vices contained three questions: reminders to take medications, nutrition and regular physical examination. The financial assistance subscale was comprised of three questions: referral for financial assistance, information about dentistry or hearing aides and financial consultation.

To examine content validity, the researcher invited five experts (three professionals in geriatric nursing and two experts in social work) to evaluate the questionnaires using a 5-point Likert scale; a higher score meant the questions were clearer and more relevant. The mean score for questions on the demographic profile, physiological and psychosocial health, ADL and IADL were all above 4.5, showing good content validity.

The content validity for the perceived health promotion needs instrument was 3.8.

Data Collection Procedure A consent letter explaining the study was given to all potential participants, and subjects were requested to sign a consent form. Five graduate nursing students, registered nurses with clinical experience in teaching hospitals, conducted face-to-face interviews pre- and post-intervention in the subjectsâ&#x20AC;&#x2122; homes. The principal investigator provided two 3-hour training sessions for them at the beginning of the data collection period. Explanations of the purposes of the study and how to administer the instruments were provided. Throughout the study, the principal investigator worked with the five students to clarify questions about the interviews and data collection. The pre-test and final interviews were conducted at each subjectâ&#x20AC;&#x2122;s home. The students read the questions to the subjects and scored the results according to the responses.

RESULTS Demographic Characteristics and Health Status The demographics of the 89 subjects are shown in Table 1. The average age was 76.8 years, with a range between 64 and 96. The majority of the subjects were male (68.5%), single (43.8%) and lived alone (31.5%). Over the half of the subjects (62.9%) had not completed their elementary school education. Chi-square was used to compare differences between groups at pre- and post-intervention. There were no statistically significant differences between groups (p > .05).

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TABLE 1 Demographic Characteristics of Low-income Elderly in Study Pre-test (n = 89)

Post-test (n = 60)

Variables

n

%

n

%

Gender Male Female

61 28

68.5 31.5

40 20

66.7 33.3

Marital status Single Married Widow/widower Divorce Other

29 30 21 6 3

43.8 22.5 23.6 6.7 3.4

24 15 17 3 1

40.0 25.0 28.3 5.0 3.4

Education Less than elementary Elementary More than+elementary

56 16 17

62.9 18.0 19.1

34 14 12

56.7 23.3 20.1

Living arrangements Alone With family With relatives and family Institutionalized Other

28 23 31 6 1

31.5 25.8 34.8 6.7 1.1

23 17 10 10 0

38.3 28.3 16.6 16.6 0

Descriptive statistics were used for presenting demographic characteristics of low-income elderly.

The subjects of the study were physically healthy; their mean scores for physical health status ranged from 1.06 to 1.77 (SD ¼ .29–1.28) before the program was implemented and ranged from 1.02 to 1.90 (SD ¼ .13–1.23) at the completion of the program (1 represented the ‘‘best’’ level and 5 the ‘‘worst’’ level of health) (Table 2). Among the 14 physical condition questions, the nutrition scores on the pre-test had a mean of 1.77 (SD ¼ 1.28). Two-third of the subjects had normal eyesight and hearing, while one-third wore corrective eyeglasses. Many of the subjects were emotionally stable (46.1%) and had a positive attitude about managing their emotional problems.

Nearly 85% of the subjects were able to carry out ADLs. Few elders had difficulties with eating, bathing, moving, hygiene, dressing or

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TABLE 2 Comparisons of Physical Health Status From Before and After Health Promotion Program (n = 60) Pre-test

Post-test

Paired t-test

Item

Mean

SD

Mean

SD

t*

p

Nutrition Sleep Circulation Comfort Sight Hearing Excretion Speech Urination Appearance Chewing Cognition Respiration Skin integrity

1.77 1.63 1.57 1.53 1.46 1.45 1.37 1.29 1.28 1.27 1.24 1.16 1.09 1.08

1.28 1.04 1.20 1.00 .74 .75 1.04 .73 .96 .56 .75 .58 .29 .38

1.23 1.58 1.22 1.90 1.49 1.31 1.26 1.24 1.32 1.17 1.17 1.17 1.02 1.08

.65 1.12 .53 1.23 .82 .62 .66 .68 .92 .38 1.38 .53 .13 .34

2.64 1.11 .703 ).725 ).206 1.069 .741 .167 ).725 .240 .216 ).206 1.0 .250

.0142** .274 .486 .472 .838 .279 .463 .868 .472 .812 .830 .838 .323 .810

Paired t tests were used to compare the differences between pre- and post-test for physical health status. * Pair-t test; **p < .05.

undressing. The mean IADL scores were higher than those of the ADLs, revealing that subjects were less independent in regard to IADL abilities (Table 3).

Outcomes of the Implementation of the Health Promotion Program Paired t-tests were used to compare differences in health status, including physiological, psychosocial, ADLs and IADLs, throughout the program.

Improvement occurred in scores for comfort, sleep, sight, bowel function, speech, appearance, chewing and respiration, though these changes were not statistically significant. The only area in which a significant difference was found between pre- and post-evaluation scores was for nutrition (paired t Âź 2.64, p < .05) (Table 2). There was

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TABLE 3 Comparisons of ADLs and IADLs From Before and After Implementation of Health Promotion Program (n = 60) Pre-test

Post-test

Item

Mean

SD

Mean

SD

Paired t*

p

ADL Eating Bathing Moving Hygiene Dressing and undressing IADL Household tasks Shopping Food preparation Laundry Chore management

1.13 1.06 1.13 1.18 1.15 1.15 1.43 1.34 1.34 1.38 1.35 1.79

.39 .28 .43 .47 .47 .47 .60 .66 .66 .68 .66 .89

1.08 1.05 1.07 1.15 1.07 1.07 1.29 1.15 1.25 1.27 1.25 1.51

.30 .22 .31 .41 .31 .31 .51 .45 .58 .58 .58 .73

)1.070 )1.000 )1.000 )1.427 – – .08 .22 .73 ).52 ).68 2.83

.289 .321 .321 .159 – – .936 .830 .472 .607 .499 .007**

*Paired-t test; **p < .05.

no statistically significant difference in subjects’ psychosocial status between pre- and post-evaluation scores.

Post test scores showed improvements in all ADLs, but the changes were not statistically significant (Table 3). The only area which saw a significant difference among IADLs between pre- and post-evaluation scores was chore management (paired t ¼ 2.85, p < .05).

Six kinds of health promotion services were assessed using paired t-tests to compare the differences between pre- and post-test for ADLs and IADLs compare differences between the pre- and post-test: medical, nursing, home-making services, caring services, health education and financial assistance services (Table 4).

The following services had significant differences of perceived health promotion service needs between the pre- and post-test: medical services referral (paired t ¼ )3.90, p ¼ .000), screening for BP (paired t ¼ )2.41, p ¼ .016), assistance in going outside (paired t ¼ )2.49, p ¼ .014), cleaning house (paired t ¼ )2.53, p ¼ .011), assistance in medical visits, (paired t ¼ )2.50, p ¼ .012), personal greeting (t ¼ )2.41, p ¼ .016), telephone greeting (paired t ¼ ) 6.00, p ¼ .000), assistance in

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TABLE 4 Comparisons of expressed needs about health promotion services from before and after implementation of health promotion program (n = 60) Pre-test (n)

Post-test (n)

Mean difference

Paired-t

p

Medical services Referral

27

11

)9

)3.90

.000***

Nursing services Nursing referral Screening for BP

11 58

3 36

)8 )22

)1.68 )2.41

.096 .016*

Home-making services Meal delivery Assistance in feeding Assistance in bathing Assistance in going outside Cleaning house Assistance in shopping Assistance in medical visit

7 2 4 10 18 6 28

0 0 2 1 3 0 10

)7 )2 )2 )9 )15 )6 )18

)1.73 )1.00 )0.58 )2.49 )2.53 )1.41 )2.50

.083 .317 .564 .014* .011* .157 .012*

Caring services Personal greeting Telephone greeting Assistance in leisure activity

55 53 46

24 2 9

)31 )51 )37

)2.41 )6.00 )4.31

.016* .000*** .000***

Health education Reminders to take medications Nutrition Regular physical examination

33 41 60

9 1 24

)24 )40 )36

)2.60 )5.19 )3.53

.009** .000*** .000***

26 20

4 4

)22 )16

.00 1.00 )2.32 .020*

35

1

)36

)4.60

Item

Financial assistance Referral Information about dentistry or hearing aides Financial consultation

.000***

Paired t tests were used to compare the differences between pre- and post-test for perceived health promotion services. *p < .05; **p < .01; ***p < .001.

leisure activity (paired t ¼ )4.31, p ¼ .000), health education for reminders to take medicine (paired t ¼ )2.60, p ¼ .009), nutrition education (paired t ¼ )5.19, p ¼ .000), regular physical examination (paired t ¼ )3.53, p ¼ .000), information about dentistry or hearing aides

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(paired t ¼ )2.32, p ¼ .020) and financial consultation (paired t ¼ )4.60, p ¼ .000) (Table 4).

DISCUSSION The percentage of subjects living alone in this study was 31.5%, which was much higher than was found in the elderly by population in Taipei (14.0%) during the same year. They require more attention to their health status and care needs in order to delay being institutionalized.22 The majority of subjects had a good level of physical health and a higher level of independence in ADLs and IADLs in this study. In studies reported in the United States and in Taiwan, the majority of elderly living alone enjoyed good physical health and had higher scores for ADL and IADL.23,24–25 Thus, maintaining a healthy and satisfactory life and keeping up functional capacity are very important for the elderly. Health promotion is the best way to promote self-reliance, to increase optimal well-being and to achieve personal completion.26 In this study, the ability of chore management could be improved significantly after implementation of the health promotion program through a service provider strategy.

Malnutrition was a common health problem in this study, and is also a significant problem for those living in poverty worldwide. According to McCally et al., malnutrition affects about 2 billion people living in poverty worldwide.27 Thus, among numerous approaches for improving the health of poor populations, the most essential task is to ensure the satisfaction of basis human needs, including shelter, clean air, safe drinking water and adequate nutrition.27 It is also the basic task for public health nurses to promote health for low-income persons.9 The causes of malnutrition can go beyond having insufficient funds for monthly living expenses; social or environmental barriers, such as inadequate diet due to the lack of health information or living alone and not having a supportive system for an adequate diet. Fortunately, nutritional status improved after implementation of the current health promotion program. Possible reasons for the low nutritional status were that some subjects did not have anyone to help them and they lacked nutritional health education.28 Home health workers in this study carried out services of health education, food preparation, shopping and meal delivery.

Welfare policy for the low-income elderly, especially for those who live alone, should focus upon providing home making services to assure that these include nutritional services.

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According to Ahluwalia et al.’s study, low-income families were less likely to draw support from their neighbors as compared to close family members and friends,28 inducing the problem of food insufficiency. Thus, suggestions raised in their study included establishing and supporting social networks between neighbors and providing appropriate education and counseling regarding food sufficiency. Some ways of accomplishing this may include mobilizing existing social networks and strengthening communities to interact with public and private service providers to address food insufficiency issues in their communities. Anti-poverty policy in Taiwan, then, should put nutrition the top priority in order to allocate the appropriate funds and resources for low-income people. Innovative approaches are needed, such as the development of partnerships between private and public sectors and between low-income persons and their neighborhoods to promote nutritional health. Low-income people may feel more isolated from neighbors due to long-term economic hardships.29 As Wilkinson, and Kawachi and Kennedy have stated, relative poverty is associated with a breakdown in social cohesion.30–31 The results of this study reveal that regular physical examinations was the most perceived health need. However, Hung and Lin’s study on health status and the needs of the elderly living alone show that 56.6% of subjects had never had any kind of health examination, in spite of the fact that annual periodic physical examinations for people older than 65 years are covered by the social welfare policy. The study reported that the lack of transportation and information about physical examinations were reasons that the elderly did not make use of the service.12 However, barriers for the unmet need of physical examination for the low-income elderly are unknown, as there are few published research articles on this topic. The need for physical examinations could be satisfied through health promotion programs, initiated by this study, which would provide transportation and information services.

Checking blood pressure was another need perceived by subjects in the study, indicating that the majority of the subjects understood its benefits and importance. After implementing the health promotion program, trained workers checked subjects’ blood pressure in their homes, which was a significant improvement over the previous situation. Thus, home-based health promotion services can satisfy subjects’ needs by addressing individual needs through assessment, referral and support.

The most commonly expressed needs for health promotion services for the low-income elderly can be satisfied through these health promotion services, especially caring, home-making and educational services. Suggestions for reshaping welfare policy for the low-income elderly

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must take the promotion of health intervention into consideration (instead of merely financial assistance) in order to prolong their independence in carrying out daily living activities. Based on low-income elderly status, perceived needs of health promotion and the effectiveness of a health promotion program, several recommendations can be made to improve independence and satisfy the needs of low-income elderly.

1. Raise public and policymaker awareness of the likelihood that low-income elderly living alone may become helpless in their homes, and promote activism within a community. Thus, anti-poverty policies in Taiwan should not be focused only upon financial assistance, but should integrate public and private, and formal and informal resources, especially providing home-based personnel services in order to prolong independency.

2. In this study, personal contact with trained health workers has been found to satisfy most of the perceived needs for health promotion services. Home workers, trained volunteers, neighbors or family members should be involved in health promotion intervention in order to decrease the social isolation of the low-income elderly.

ACKNOWLEDGMENTS The author thank the Taipei Welfare Department for funding and assisting this program. Special thanks to all low-income workers and elderly for participating in this study.

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